D67

AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST

Grade D 67/100 composite score

For profit - Limited Liability companyAbuse Citation

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
2/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

82

Ownership

For profit - Limited Liability company

Total Fines

None

Last Survey

N/A

3939 PENHURST AVENUE, BALTIMORE, MD 21215
4106649535

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.38h
LPN
1.14h
CNA
1.88h
Total
3.40h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

AWCC HOLDCO LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jun 2019

100%

SIYATA DSHMAYA LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jun 2019

8%

MEISELS, MORRIS

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jun 2019

42%

STERN, ARYEH

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jun 2019

50%

GIBSON, LISA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2019

SCHWARTZ, MARK

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Dec 2021

SCHWARTZ, MARK

IndividualCORPORATE OFFICERSince Mar 2025

AWCC REALTY HOLDCO LLC

Organization5% OR GREATER MORTGAGE INTERESTSince Jun 2019

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (45)

June 17, 2025Health4 deficiencies
0584DMinimal harm, Isolated

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies

Corrected Jul 29, 2025
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 29, 2025
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Jul 29, 2025
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 29, 2025
May 6, 2022Health29 deficiencies
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Jul 5, 2022
0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Jul 5, 2022
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Jul 5, 2022
0585CNo harm, Widespread

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Corrected Jul 5, 2022
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 5, 2022
0610EMinimal harm, Pattern

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 5, 2022
0622DMinimal harm, Isolated

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Resident Rights Deficiencies

Corrected Jul 5, 2022
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Jul 5, 2022
0624DMinimal harm, Isolated

Prepare residents for a safe transfer or discharge from the nursing home.

Resident Rights Deficiencies

Corrected Jul 5, 2022
0625DMinimal harm, Isolated

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies

Corrected Jul 5, 2022
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 5, 2022
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 5, 2022
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jul 5, 2022
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Jul 5, 2022
0688EMinimal harm, Pattern

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Corrected Jul 5, 2022
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Jul 5, 2022
0692EMinimal harm, Pattern

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Jul 5, 2022
0732CNo harm, Widespread

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Jul 5, 2022
0756EMinimal harm, Pattern

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Jul 5, 2022
0761DMinimal harm, Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Jul 5, 2022
0791DMinimal harm, Isolated

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Corrected Jul 5, 2022
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jul 5, 2022
0842EMinimal harm, Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 5, 2022
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jul 5, 2022
0883EMinimal harm, Pattern

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Jul 5, 2022
0885CNo harm, Widespread

Report COVID19 data to residents and families.

Infection Control Deficiencies

Corrected Jul 5, 2022
0886EMinimal harm, Pattern

Perform COVID19 testing on residents and staff.

Infection Control Deficiencies

Corrected Jul 5, 2022
0887EMinimal harm, Pattern

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Infection Control Deficiencies

Corrected Jul 5, 2022
0608DMinimal harm, Isolated

Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 5, 2022
November 1, 2018Health12 deficiencies
0559DMinimal harm, Isolated

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Resident Rights Deficiencies

Corrected Dec 8, 2018
0578DMinimal harm, Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Corrected Dec 8, 2018
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 8, 2018
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 8, 2018
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Dec 8, 2018
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 8, 2018
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Dec 8, 2018
0700DMinimal harm, Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Quality of Life and Care Deficiencies

Corrected Dec 8, 2018
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Dec 8, 2018
0625DMinimal harm, Isolated

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies

Corrected Dec 8, 2018
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 8, 2018
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Dec 8, 2018

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Frequently Asked Questions

What is the CareGrader rating for AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST?

AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST in BALTIMORE, Maryland has a CareGrader grade of D (Below Average), with a composite score of 66.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST?

AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST have?

AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST has 45 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

How many beds does AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST have?

AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST has 82 certified beds with approximately 76 current residents (93% occupancy). The facility is located at 3939 PENHURST AVENUE, BALTIMORE, Maryland 21215. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.